Enrollment Questions


Contract Questions


Reimbursement and Payment Questions


Claims Submission Questions


Understanding Medicare Part D



Enrollment Questions


Is there a cost to enroll or to process claims through the portal?


No: There is no cost to the physician to enroll in the TransactRx Provider Network or to process claims through the myTransactRx.com portal. Costs are included in the reimbursement rates.


Can I enroll multiple practice locations (sites) under one account?


Yes. The myTransactRx.com portal supports many business configurations.


The simplest configuration is an Account with one location. This Account can be enrolled with one Site. Billing and payment information can be entered either at the Account level.


For Accounts that have multiple locations (Sites), all Sites should be entered as part of the one Account enrollment process. First enter the central Account information and then the application will ask you to enter information for each of the Sites. If all billing is done centrally at the Account level using one Tax ID/NPI then enter that information in the Account form. If billing is done at a Site level under separate Tax ID/NPI numbers then enter that information at the Site level.


Payments can be configured to be sent to one central bank account or address or can be sent to individual Sites.


Do all physicians within the practice have to participate?


No: Enrollment can be limited to physicians who want to participate.


If physicians within the practice have a different TAX ID, do they need to enroll separately?


Yes: Physicians practicing out of the same location, but who are paid under a different TAX ID are recognized as separate entities for enrollment and payment purposes. A separate Site enrollment is required for each TAX ID that will be used to submit claims.


Can I get paid directly through an ACH transaction?


It is easy to enter your bank account information during the enrollment process so that payments can be made directly to your bank account. If desired payments can be made via check. There is a nominal charge of $2.50 for payment by check. There is no charge for payments submitted by ACH.


Do I need an NPI?


Yes. Under the NPI Final Rule (69 FR 3434), a health care provider who is a covered entity under HIPAA is required to obtain an NPI and to use it to identify itself as a health care provider in HIPAA transactions no later than May 23, 2007. Small health plans must use the NPI no later than May 23, 2008. A health care provider is a covered entity if it transmits any health information in electronic form in connection with a transaction for which the Secretary has adopted a standard (Redundant to above). For example, any health care provider (individual or organization) who sends electronic health care claims to a health plan(s),is a covered provider and must obtain an NPI. Health care providers who are not covered providers may elect to apply for NPIs, but are not required to do so. For the latest information regarding NPI issues for health care providers, visit this website: www.cms.hhs.gov/NationalProvIdentStand/


Do I need a NPI for each physician to submit claims for drug product reimbursement?


Yes. All pharmacies and other dispensing providers are required to use the NCPDP format adopted as a HIPAA standard for submission of prescription drug claims to Medicare. As of May 23, 2007 and later, only an NPI may be reported for identification of dispensing providers and prescribing physicians. NCPDP claims received by Medicare after May 22, 2007 that lack an NPI for either the dispensing provider or the prescribing physician will be rejected.


Is the myTransactRx.com HIPAA compliant?

Yes. The myTransactRx.com portal complies with all security and transaction standard requirements under HIPAA.


How will I know which plans TransactRx is contracted with?

You will receive an electronic message whenever new contracts are added. A list of contracts can also be viewed within the myTransactrx.com Portal.


What if I am not a contracted provider for some of the plans TransactRx is contract with?


You do not need to be contracted with all of the plans TransactRx is contracted with. It is possible that your patients� pharmacy coverage is with a different insurance provider than their medical coverage. If TransactRx is contracted with that plan, you are considered a contracted provider for drug products covered by pharmacy benefits.


What happens if I have a problem or interruption while completing the enrollment, can I stop and go back later to finish?


Yes, click on Finish Later anytime in the enrollment process. When you are ready to continue, log-in under your username and password that you set up in the first step of the enrollment process.


Contract Questions


Is there a cost to participate in the TransactRx Provider Network?


There are no billed charges to the physician. Costs are calculated into the reimbursement rates. There is a nominal $2.50 fee for the printing and mailing of remittance checks if you do not elect ACH transfers (direct deposit to your bank account).


Can I make changes to the contract?


No: The contract terms and conditions are tied to the terms and conditions we have with third party payers. Changes to the provider contract would violate these terms.


Can I terminate the contract without cause?


Yes: The contract provides a 90 day no-cause termination clause.


Do I need to send copies of my DEA, malpractice insurance, or other information in order to execute the contract?


No: The information captured online during the enrollment process is validated based on the information entered. There is no need to submit further hard copies of this information. If regulations change, or if you begin to administer vaccines or medications that are considered controlled substances, we may ask for copies of information at that time.


Do I have to commit to a certain volume?


No: There are no volume requirements.


What if I am not a contracted provider for some of the plans TransactRx is contracted with?


You do not need to be contracted with all of the plans TransactRx is contracted with. It is possible that your patients pharmacy coverage is with a different insurance provider than their medical coverage. If TransactRx is contracted with that plan, you are considered a contracted provider for contracted drugs covered by pharmacy benefits.


Reimbursement and Payment Questions


How often will I get paid for submitted claims?


Payments will be made from TransactRx to physician offices on a monthly basis which will represent all payments received from all payers during that payment period.


How will I know how much I will be paid for each Vaccine?


As with medical professional fees, reimbursement varies by plan. The amount you will receive for each vaccine is displayed when you submit a Coverage Inquiry or claim. The patient�s responsibility will be displayed at the same time. The myTransactRx.com Help menu will provide an overview of contract terms by plan, but this information is general in nature and not specific to plan coverage.


What if I do not want to accept the amount to be paid, because I think it is too low?


TransactRx has made every effort to assure contract rates (reimbursement to physicians) are at market, sufficient of cover the cost of the drug product and provide a profit for the physician. Participation in the network obligates physicians to accept this reimbursement for the drugs physicians administered to patients covered by payers contracted with TransactRx. If you do not find the reimbursement acceptable you can elect not to provide the medication, and cancel the claim. Balance billing is prohibited.


Can a provider administering a Part D vaccine charge the beneficiary a separate administration fee?


During 2007:

During 2007 a separate claim must be submitted under Part B for the administration of a covered Part D vaccine. Payment under Part B for administration of a Part D-covered vaccine is available only if the Medicare beneficiary is enrolled in a Part D Prescription Drug Plan and only if the Part D-covered vaccine is furnished to the beneficiary.

CMS has created a G code (G0377: Administration of vaccine for Part D drug) to be used for the administration of Part D-covered vaccines in 2007. The Part B allowed charge for G0377, effective for 2007, is $19.33. Thus, the Medicare payment would be 80% of that amount or $15.46, assuming the beneficiary's Part B deductible is met. The beneficiary would pay $3.87 as a coinsurance payment, plus any Part B deductible payment that may be due.


Starting January 1, 2008

Effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of covered Part D drug under the Part D statute and is required to be billed as part of the Part D claims process.


Claims processed through TransactRx Vaccine Manager after December 31, 2007 will include the administration fee associated for vaccine submitted. The amount that will be paid for the vaccine and the administration fee will be provided.


What if my patient brings a vaccine from a retail or specialty pharmacy for me to administer, can I use Vaccine Manager to process the administration fee?


Industry standards for processing vaccine claims do not support electronic submission administration only claims. DSI is working with NCPDP (National Council for Prescription Drug Plans to identify a possible solution for administration only vaccine claims. Until a solution is identified administration only claims should be submitted to the Part D plan on a paper CMS 1500 form.

Why are some patient collect amounts (copayments/deductibles) so high?

Depending on the patient's benefit plan and where the patient falls in their deducible cycle or "donut hole" (a period with no benefit coverage) they could have an out of pocket responsibility of up to 100% of the allowable charge. This is most common at the beginning of the benefit year. Patients will need to meet this deductible regardless of where they receive their pharmacy services. Once the deductible is met most patients will only be responsible for a small co-payment.


Are patient out of pocket costs for drugs processed through TransactRx applied to the patient TrOOP (true out of pocket costs)?


Yes, claims processed through TransactRx and the associated out of pocket costs are managed by the payer in the same way they manage claims processed by a retail network pharmacy.


Claims Submission Questions


When can I start submitting claims?


Once the online enrollment process is completed you will receive an email confirming your enrollment. The TransactRx enrollment group will review your enrollment information, complete the provider credentialing process and then activate your account. When the Account is activated an email will be sent to the Primary Administrative User specified during the enrollment process. Once this confirmation is received you will be able to log on to the myTransactRx.com portal and begin submitting claims.


Do I have to collect a co-pay or deductible from my patients?


Yes: Our contracts with third party payers require collection of co-payments and deductibles as indicated on the coverage inquiry screen. Payments made to you are calculated at the total contracted reimbursement less the co-payment collected.


Do I have to have the patient sign anything?


Yes: The patient must sign a patient medication administration log indicating they received the medication and authorize you to submit and collect payment for the medication provided. Signature logs are provided in the TransactRx Enrollment Packet.


What if my patient does not want to pay for their co-pay or deductible?


If you have administered the medication, you should follow the same collection and patient discount/write-off procedures you follow for other professional services. If you did not administer the medication, simply cancel the pending claim.


What should I do if a patient refuses the medication after I completed a coverage inquiry?


Simply cancel the claim. This can be done at the Coverage Inquiry screen, or in the Claims Management module.


What do I do if I submitted a claim in error?

Simply cancel the claim. This can be done at the Coverage Inquiry screen, or in the Claims Management module.


How long do I have before I have to submit or cancel pending claims?


You have 24 hours (one business day) to submit or cancel pending claims. Claims sitting in the Claims Management module will automatically cancel if no action is taken within this time period.


Do I have to have the patient sign anything?


Yes: The patient should sign the patient log indicating they received the medication and authorize you to submit and collect payment for the medication provided. Signature logs are provided in your TransactRx Enrollment Packet.


Understanding Medicare Part D


What is Medicare Part D?


The Medicare Prescription Drug Coverage (Part D) is a voluntary prescription benefit available to Medicare beneficiaries.


What is the difference between Part A, B and C benefits?


Part A benefits cover inpatient, skilled nursing facility and some home health care.


Part B benefits cover Medicare eligible physician services, outpatient hospital service and some home health and durable medical equipment. It also covers influenza and pneumonia vaccines, hepatitis B for intermediate to high risk beneficiaries and any medically necessary vaccines to treat illness or injury.


Part C, also known as Medicare Advantage plans, provides Medicare covered health services through a Medicare private health plan (HMO, PPO, Fee for Service plan).


Part D covers medication and vaccine prescriptions.


Does a beneficiary have to pay for Medicare Part D benefits?


Most plans have a monthly premium requirement. The amount of the premium is usually depended on the type of plan selected. Lower deductible plans with fewer formulary restrictions will usually result in a higher monthly premium.


Who is eligible for Medicare Part D?


Medicare Part D is available to individuals who are entitled to Medicare benefits under Medicare Part A or who are enrolled in Medicare Part B. They must reside in the service area of the Medicare prescription plan selected.


What is the basic Medicare Part D coverage model?


The basic Part D plan is made up of four parts.


Part 1 - An initial deductible of $275.00. Some plans waive the deductible, but these same plans may have a higher monthly premium.


Part 2 - Beneficiaries are required to pay a co-payment or coinsurance for each prescription until the retail cost of the medications reaches $2,150. Some plans may lower the the limit to $2,000 or $1,850 which usually results in lower monthly premiums.


Part 3- Once the beneficiary reaches the coverage limit defined above, they enter into a coverage gap or "donut hole". At this point beneficiaries are responsible for 100% of their medciation costs. Some plans provide partial or complete coverage for this gap in the Medicare Part D coverage.


Part 4 - Once a beneficiary�s true out of pocket costs exceeds $4050 for prescription medications they enter into to the "catastrophic coverage" where the cost of medications is substantially reduced. The $4050 does not include the portion of prescription medications paid by the insurance company, nor does it included premiums paid by the beneficiary. Cost of medication during the catastrophic phase ranges between $2.25 for generics and the higher of 5% of the cost of the medication or $5.6 for brand medications.


What is TrOOP Cost (True Out Of Pocket Costs)?


TrOOP is the total out of pocket costs for covered medications. It includes all of the payments for medications listed on a plan's formulary that are purchased at a network/participating pharmacy. It includes the amount of deductible and co-payments paid by the beneficiary. It does not include over the counter medications or medications purchased out of the country.